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Acute Stroke Unit Orientation 1Module 6: Swallowing, Nutrition and Oral Care

ACUTE STROKE UNIT ORIENTATION

2018

SWO Stroke Network, 2018. Adapted from NEO Stroke Network (2010).

MODULE 6: SWALLOWING, NUTRITION AND ORAL CARE

Learning Objectives

Upon completion of this module, nurses will be able to:

• Define dysphagia

• List the complications associated with dysphagia

• Understand the mechanics of a normal swallow

• List signs of swallowing problems

• Define silent aspiration

• Identify a screening tool for dysphagia

• Understand the purpose and goals

of dysphagia management

• Explain the indications, risks and benefits

related to enteral nutrition

• Understand proper feeding strategies

• Understand the importance of and

methods for oral care


*NOTE the difference between these two terms:

Dysphasia/Aphasia is a

language disorder in which there is an impairment of the

comprehension and expression of language.

Dysphagia is a medical

term defined as “difficulty swallowing.”

6.1 Swallowing Post-Stroke: Dysphagia

Dysphagia is a significant consequence of stroke. Optimal

stroke care includes identifying and managing dysphagia.

Key Points about Dysphagia:

• The loss or the impaired ability to chew and/or swallow

• Characterized by a disturbance in the swallowing

mechanism

• Difficulties include choking, coughing, excess drooling,

and the inability to manage secretions

• Presentation is varied and difficulty can occur in one

or more of the swallowing phases

• Risk increases with the elderly population

Studies indicate that approximately 50% of acute stroke

patients have some degree of dysphagia within the first 72

hours after the stroke (Kidd D et al., 1995). Dysphagia may

resolve in some patients but can be longstanding in others.

From the Registered Nurses Association of Ontario (RNAO):

Stroke Assessment across the Continuum of Care, 2011, p. 18:

6.1 – Nurses in all practice settings who have the appropriate

training should screen within 24 hours of the client becoming

awake and alert for risk of dysphagia using a standardized

tool. This tool should also be completed with any changes in

neurological or medical condition, or in swallowing status. In

situations where impairments are identified, clients should be

kept NPO and referred to a trained healthcare professional for

further assessment and management.


Quick facts:

In total, more than 200,000 people suffer from dysphagia

in Canada at any given time

Visible signs of swallowing difficulty exist in 80%

of the institutionalized elderly

The risk of developing aspiration pneumonia in the stroke survivor is 7x greater

when dysphagia is present (Singh and Hamby, 2006)

The cost of treating pneumonia

in Canada has been estimated at $1,000 per

day of hospitalization (Steele et al, 2008)

Stroke can affect one’s ability to eat or swallow when:

• Muscles involved in feeding, swallowing, or

breathing are affected

• Alertness and attention to eating are affected

• Independence for eating is taken away

Swallowing Problems Related to Aging:

• Decreased peristalsis in the esophagus

• Decreased lung function

• Decreased muscle strength

• Decreased saliva

• Problems with dentition

Complications Associated with Dysphagia

Dysphagia can have a serious impact on one’s health, leading

to other serious conditions such as:

• Airway obstruction

• Aspiration pneumonia

• Malnutrition

• Dehydration

• Reduced quality of life


Malnutrition and Stroke

Inadequate energy and protein intake is highly prevalent

in stroke patients. The majority of stroke patients do not

consume their estimated requirements.

• Identifying malnutrition in stroke patients is

critical; 16% of acute stroke patients admitted

to hospital are malnourished.

• Malnutrition increases the risk of pneumonia

and other infections.

• Malnutrition after stroke is associated with poor long-

term outcome (i.e., decreased functional status, physical

decline, increased length of stay in hospital etc.).

• It is critical to begin appropriate nutrition as soon as

possible.

For more information, refer to the 2013 Canadian Best Practice

Recommendations for Stroke Care: Acute Inpatient Stroke Care,

4.2.6 - Nutrition and Dysphagia.

Dehydration and Stroke

According to the Heart and Stroke Foundation of

Canada’s Tips and Tools (2010):

Survivors with swallowing problems may fear choking and avoid

drinking fluids. Survivors who fear incontinence may decrease

their fluid intake in an attempt to prevent accidents, while

others may be unable to communicate that they are thirsty.

• Dehydration increases the risk of falls, infection (urinary

tract), constipation, and deep vein thrombosis.

• Those who require help eating or drinking, refuse fluids

at meals, or are on thickened fluids are at an increased

risk for dehydration.

• Signs of dehydration include dizziness upon standing,

confusion or change in mental status, rapid weight loss,

thick, stringy saliva, decreased urine output, and dark

concentrated urine.


Hydration and Thickened Fluids

Stroke patients on thickened fluids are at increased risk of

inadequate fluid intake, which leads to dehydration. This is

due to the reduced level of free water content in the thickened

fluids and overall reduced total fluid intake. Stroke patients

need to be encouraged to consume the thickened fluids on

their meal trays.

Goals of Dysphagia Management

• Maximize nutrition

• Protect airway from obstruction

• Protect airway from aspiration

• Manage reflux

• Control oral bacteria

• Monitor medication intake

• Monitor and maintain fluid intake for hydration

*Dysphagia management is the key to preventing aspiration

and aspiration pneumonia (see section 6.3 Aspiration). If any

signs of dysphagia are noted, the patient should be made NPO

for further assessment.

Consult the Dietitian if there is a concern on the amount

of fluids your patient is consuming, or if the patient is

at risk of malnutrition.


6.2 Normal Swallow

Swallowing is a semi-automatic motor action involving the

movement of food from mouth to stomach. The average adult

swallows 1500 times per day. While awake, we swallow once

every 60-120 seconds.

A normal swallow has four phases:

1. Oral Preparatory Phase

2. Oral Transport Phase

3. Pharyngeal Phase

4. Esophageal Phase

1. Oral Preparatory Phase

• The initial stage whereby food and drink are brought to

the mouth, and the lips and the jaw close to seal the

mouth and saliva is produced to add moisture

• Under voluntary control

• Food is chewed and mixed with saliva to form

a bolus (ball of food)

2. Oral Transport Phase

• Bolus is delivered by voluntary tongue movement to

the back of the mouth, into the pharynx

3. Pharyngeal Phase

• Involuntary/reflexive phase– lasts 800 milliseconds

• Triggered when food passes towards the

esophagus and the soft palate closes

• Pharynx and larynx move up to protect the

airway and direct the bolus to the esophagus


4. Esophageal Phase

• Involuntary/reflexive

• Relaxation of the upper part of the esophagus

• Peristalsis pushes the bolus down into the stomach

• Gravity also assists with bolus transportation

Signs of Swallowing Problems

It is important to notice these crucial signs

that may indicate your stroke patient is having

difficulty swallowing:

• Drooling

• Slow eating, prolonged chewing

• Food left in mouth after eating (e.g., residue or pocketing)

• Pain associated with swallow

• Effortful swallow

• Delayed initiation of swallow

• Coughing or choking during and/or after swallowing

• Throat clearing after swallowing

• Voice changes (i.e. wet/gurgly voice)

• Refusal to eat or drink

• Recurrent chest infections

• Unexplained weight loss

• Gagging

• Nasal regurgitation

• Shortness of breath

• Poor lip closure with loss of food from mouth

• Increase in temperature

(Heart and Stroke Foundation, Tips and Tools, 2010)


A Few Words about Reflexes…

Absence of a gag reflex does not predict dysphagia

Presence of a gag reflex does not protect against aspiration

The cough reflex can be impaired or absent, so

silent aspiration may occur

6.3 Aspiration

Aspiration is the entry of food or liquid into the airway below

the muscles that produce sound, the vocal folds (Rosenbek

JC et al., 1996).

Bacteria in saliva, foods and liquids, or refluxed material from

the stomach can enter the airway. It can lead to choking or

breathing problems. If this material enters the lungs, it can

cause an infection, typically aspiration pneumonia.

Martino et al., (2005) found that patients with dysphagia

after stroke have a 3 times greater risk of pneumonia than

stroke patients without dysphagia, and when those dysphagia

patients were confirmed as aspirators their relative risk rose to

11 times greater.

Incidence of aspiration in stroke

• 50% aspirate immediately after the brain insult

• 25% die of aspiration pneumonia within the 1st year of

rehabilitation (American Academy of Otolaryngology – Head

and Neck Surgery, 2006)

• Patients with infarctions of the brain stem, multiple

strokes, major hemispheric lesions or depressed

consciousness are at increased risk of aspiration (AHA,

2013 – Acute Guidelines)

• An abnormal gag reflex, impaired voluntary cough,

dysphonia (wet voice), incomplete oral-labial closure, a

high NIHSS score, or cranial nerve palsies should alert the

interprofessional team to the risk of dysphagia

• A preserved gag reflex may not indicate safety

with swallowing


Remember chest x-ray key terms:

Consolidation – the lung is filled with liquid or a mark of swelling/ hardening of

normal soft tissue

Infiltrate – abnormal substance has

infiltrated the lungs

Atelectasis – a collapse or closing of the lung

resulting in reduced or absence gas exchange

Pleural effusion – excess

fluid that accumulates between the two pleural

layers, the fluid-filled space that surrounds the lungs

Silent Aspiration

Coughing is a physiologic response to aspiration in normal

healthy individuals, but aspiration is not always accompanied

by coughing. Silent aspiration means there are no clinical

signs of aspiration (no coughing or throat clearing). It is very

common. In fact, lack of coughing is prevalent in 40% of

aspirators (Logemann, 1983).

When silent aspiration is occurring, it is not until respiratory

complications occur that we realize the patient has been

aspirating.

How do you detect silent aspiration?

When a stroke patient presents with high risk of

aspiration, we closely monitor temperature, fever,

white blood cell count, and chest to detect any new

infection.

If the patient is silently aspirating, they will not cough or clear

their throat at bedside.

It is important to evaluate overall respiratory status and

consider the patient’s likelihood of being able to protect

themselves from further infection when evaluating feeding

options.


6.4 Dysphagia Screening

What is a screening tool?

A swallowing/dysphagia screening tool indicates

likelihood of the presence or absence of dysphagia

and identifies patients who require a referral to a

Speech-Language Pathologist for a full swallowing assessment.

The Heart and Stroke Foundation (HSF) and

Registered Nurses’ Association of Ontario (RNAO)

(2005) publication entitled, Stroke Assessment

across the Continuum of Care, suggests

that a dysphagia screening tool contain:

• Assessment of the client’s alertness

and ability to participate

• Direct observation of the oropharygeal

swallowing difficulty (choking, coughing, wet voice)

• Assessment of tongue protrusion

• Assessment of pharyngeal sensation

• Assessment of voice quality

• Administration of a 50mL water test

• Evaluation of the patient’s voice quality,

oromotor function, oral sensation, and ability to cough

• Trials of water using a present protocol

What are some examples of swallowing screening tools?

Massey Bedside Swallowing Screen

The Massey Bedside Swallowing Screen is a 14 point screen

that examines alertness level, dysarthria, aphasia, oral motor

abilities, gag reflex, and incorporates a one teaspoon water

swallow followed by a 60mL water swallow.


Timed Test of Swallow and Questionnaire

Each patient answers a standard questionnaire related to

his or her swallowing. If swallowing, the patient undergoes a

limited timed test. The timed test involves 5-10 mL of water

from a teaspoon. Patients choking on this amount do not

proceed to the full test and are recorded as an abnormal test.

If the patient passes then 50- 100 mLs of water is given and

the patient is asked to drink the water as quickly as possible.

Any residual water is measured as are the number of swallows.

The test is abnormal if either the quantitative or the qualitative

aspects of the swallow are outside the normal limits.

Toronto Bedside Swallowing Screening Test (TOR BSST)

The TOR BSST screen includes 4 clinical test items: dysphonia,

‘voice before’ and ‘voice after’, tongue movement, and water

swallows using a preset protocol.

Screening Tool for Acute Neurological Dysphagia (STAND)

The STAND screening tool evaluates patients’ alertness and

oxygen saturation levels, voice quality and ability to manage

oral secretions, and history of dysphagia. It also includes a

swallow challenge with pureed foods and water and while the

assessor observes for specified signs of impaired swallowing.

Standardized Swallowing Assessment (SSA)

SSA consists of a general evaluation (e.g., conscious level,

postural control) in order to ensure the patient is physically

capable of undertaking screening. The screening tool then

assesses the patient’s breathing, voice control, saliva control,

as well as his or her ability to cough, sip water from a spoon,

and drink water from a glass.


The Barnes-Jewish Hospital Screen

The Barnes- Jewish Hospital Screen assesses consciousness,

dysarthria and has a 3 ounce water trial to identify any signs of

aspiration.

*Refer to the screening tool used in your organization

6.5 Managing Dysphagia and Feeding Your Stroke Patient

Dysphagia Diets

As there is no standard classification for diets,

please check with your own facility or organization

regarding available diet for patients with dysphagia.

The Speech-Language Pathologist in conjunction with

the Dietitian will identify the most appropriate diet for the

individual patient.

Nutrition Support: Enteral Nutrition

2013 Canadian Best Practice Recommendations for Stroke

Care: Rehabilitation 5.7.2 state that enteral nutrition support

should be considered as early as possible after admission,

usually within the first three days if a patient is unable to meet

their needs orally or if NPO status is considered:

ii. Stroke patients with suspected nutritional concerns,

hydration deficits, dysphagia, or other comorbidities that

may affect nutrition (such as diabetes) should be referred to

a Dietitian for recommendations:

a. To meet nutrient and fluid needs orally while

supporting alterations in food texture and fluid

consistency recommended by a Speech-Language

Pathologist or other trained professional [Evidence

Level B];


b. For enteral nutrition support (nasogastric tube feeding

in patients who cannot safely swallow or meet their

nutrient and fluid needs orally.

c. The decision to proceed with tube feeding should be

made as early as possible after admission, usually

within the first three days of admission in collaboration

with the patient, family (or substitute decision maker),

and interprofessional team [Evidence Level B].

Nasogastric (NG) Feeding Tube

NG feeding tubes are used for short-term nutrition support.

They allow an immediate route for nutrition, hydration and most

medications. Average use is less than 4 weeks. The nares

should be checked periodically for breakdown and soreness.

Common benefits of using NG tube:

• Provides immediate route to provide nutrition,

water, and medications

• Allows patient to be nourished and hydrated when

some recovery of swallowing ability is expected

within a short-time period (1-3 weeks)

Common risks of using NG tube:

• Patient may pull NG out, as it is easily accessible

• Hands may need to be restrained if repeatedly pulled out

• Smaller tubes clog more easily

• May cause reflux, possible aspiration pneumonia

• May cause an increase in secretions and sinusitis

• Not all medications can be put through an NG tube

*If no progress in 1-3 weeks, PEG Tube or gastrostomy tube should be

considered for longer-term tube feeds.


Percutaneous Endoscopic Gastrostomy (PEG) Feeding Tube

PEG feeding tubes are used for longer term nutrition support

(greater than 4-6 weeks). It can be inserted endoscopically,

radiologically, CT-guided or surgically. Consider PEG placement

for enteral feeding lasting longer than 28 days, as this time

frame has been associated with fewer complications.

Feeding Your Stroke Patient

Feeding is a skill that requires knowledge and experience.

Safe, low-risk feeding practices should be used with all

patients, but are especially important with patients requiring

full feeding assistance. This helps to prevent serious health

problems and improve the quality of the experience for the

patient.

Consider the placement of food in front of the survivor to

accommodate for neglect (see Module 9: Cognition, Perception,

and Behaviour).

To ensure patient safety, one must consider:

• Positioning for feeding

• Safe feeding techniques and strategies

• Mouth care

• Dysphagia diets

• Thickened fluids

Patients who are fed by others are at an increased risk of

aspiration, so stroke survivors should be encouraged and

assisted to feed themselves when possible.

Patient Positioning

• Sit fully upright with a slight chin tuck

when eating and/or drinking


Feeder Positioning

• Eye-level with the patient

• Across from the patient

• Feeder should be comfortable

• Do not feed from above the mouth

Feeding Strategies

• Check the tray to ensure the correct diet has been provided

• Feed at a relaxed pace

• Ensure patient has swallowed before giving the next bite,

watch and feel the swallow

• Small amounts of ½ to one teaspoon at a time

• Do not engage in conversation with patient when there is

food or liquid in their mouth

• It is permissible to engage in conversation once their

mouth is empty, as this is a way to check vocal quality

(listen for wet voice)

• Use hand-over-hand support with dysphagic patients who

cannot self-feed

• Cue patients to feed on the strong side of their mouth (i.e.,

present utensil or cup to non-affected side)

• Reduce distractions

• Provide one pill at a time (crush if necessary)

*Consideration: is pill crushable?

• Patient should remain upright for at least 30 minutes after meal

• Complete mouth care after each meal

• Use assistive devices; rimmed plates, a gripper pad to

prevent dishes from slipping, cup or glass holders, modified

utensils with built up or bent handles, etc. (Heart and

Stroke Foundation, Tips and Tools, 2010)


Dangerous Practices

According to the Heart and Stroke Foundation of Ontario’s

Improving Recognition and Management of Dysphagia in Acute

Stroke, A Vision for Ontario 2005, the following practices may

have significant clinical consequences, including aspiration or

dehydration, for individuals with dysphagia:

• Feeding someone who is not alert

• Syringe feeding

• Feeding in a fully or partially recumbent position

• Giving pills with water to individuals on a ‘no thin fluids’ diet

• Unnecessarily restricting diet to thickened and puree

• Feeding with a tablespoon rather than a teaspoon

• Giving anything not approved in the diet; tell family, other

staff members, and visitors to check if specific food items

are allowed before they bring them

Other Considerations

Weight

It is important that all stroke patients are weighed upon their

admission to the medical floor. This will serve as a baseline

weight so that the Dietitian can determine that any weight loss

is occurring during their hospital stay. Weights can be recorded

in the patient’s chart.

Intake Records

Food intake records can be ordered by the Physician and/

or Dietitian for a set number of days to better determine

if a stroke patient’s oral intake is meeting their estimated

nutritional needs. Please use the menu tickets, if available, on

a patient’s meal tray to mark the approximate amount of each

food consumed. In some centres, these menu tickets are kept

on the front of the patient’s chart for the Dietitian to view.


6.6 Oral Care

The objective of proper mouth care is to maintain the mouth in

a comfortable, clean, moist and infection-free state.

To be effective, oral care must include cleaning the:

• Entire oral mucosa

• Tongue

• Teeth

• Sulci (spaces between the cheeks and gums)

Thorough and effective mouth care is required to maintain a

healthy oral environment on all patients, especially if they are:

• Unconscious

• NPO; for these patients, mouth care

should be performed a minimum of bid

• Eating and drinking minimally

• Have impaired oral sensation

For patients receiving thickened fluids:

If patient has been prescribed a mouth care agent

(e.g., nystatin), ensure it is ‘swabbed on’ due to risk

of aspiration; patient cannot “swish and swallow” but

may be able to “swish and spit”.

Consider consulting Dentistry, Occupational Therapy, Speech-

Language Pathologists, and/or a Dental Hygienist to develop an

oral care protocol (National Stroke Nursing Council, 2010).


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